COVID‐19 transmission flow through the stigmatization process in Bangladesh: A qualitative study

Abstract Introduction Coronavirus disease (COVID‐19) patients and survivors face stigma, discrimination, and negligence. The motives for and the different types and consequences of COVID‐19‐related stigmatization remain underexplored in Bangladesh. Therefore, this study examined how the COVID‐19 stigmatization process is interlinked with transmission flow. Methods Using a qualitative research design, we conducted 20 in‐depth interviews with infected and suspected caregivers and five key informant interviews with physicians, local media representatives, leaders, law enforcement officials, and local administrative officials in three divisional cities of Bangladesh. We performed thematic analysis to analyze the data. Results Participants expressed their experiences with multiple subthemes within three themes (stigma related to symptoms, stigma associated with isolation and quarantine, and stigma associated with health services). Participants reportedly faced stigma, for example, exclusion, hesitation to interact, avoidance, bullying, threat, and negligence caused by misinformation, rumors, and fear. Stigmatized individuals reportedly hid their symptoms and refrained from seeking healthcare services, contributing to COVID‐19 transmission flow. Conclusion Revealed insights may contribute to effective prevention, control, and management of such an emerging pandemic. Further in‐depth exploration of such stigmatization process will enrich unexpected outbreaks management effectively.


INTRODUCTION
The coronavirus disease  poses unprecedented threats to global public health. Until August 2021, COVID-19 caused 4.5 million deaths and negatively affected everyday life worldwide. 1 In specific, the COVID-19 has disrupted daily life activities, socioeconomic systems, and access to healthcare in low-, middle-, and high-income countries. 2,3 Individuals possess limited knowledge about this novel virus, resulting in fear, discrimination, and stigma. During a pandemic or an epidemic, fear exacerbates stress and psychological symptoms. 4,5 Because, the novelty and rapid spread of the COVID-19 and the associated uncertainty, fear levels have been higher during the ongoing pandemic than in past epidemics. 6 During a pandemic, individuals are vulnerable to social isolation, a lack of access to healthcare services, harassment, and bullying. In addition, individuals with active COVID-19 symptoms have been found to hide their symptoms when accessing healthcare services because of their fear of stigmatization. 7 Understanding the COVID-19 transmission flow and the associated stigma process is crucial to respond to this pandemic effectively. To date, little has been explored about the COVID-19 transmission flow interlinking with the stigma process.
It is essential to understand the definition of stigma to identify the COVID-19 transmission flow through the stigma and its internalization process. The idea of stigma owes a great deal to Goffman, who viewed stigma as a social construction of identity, the situation of the individual who is disqualified from full social acceptance. 8 Stigma is located within the stigmatized person and the social context that explains a devaluing attribute. Goffman further identified that the stigma occurs as a discrepancy between the "virtual social identity" where individuals are characterized by society and "actual social identity" where a person possessed the attributes. 8 A recent study identified that the COVID-19 patients are being treated as 'other' that can also be categorized them as stigmatized. 9 The power relation is central to construct the stigmatization where the ordinary people (such as a healthy individual) control the social, economic, and political power. 10 Therefore, stigmatization is attributed to society's dominant group, and the stigmatizing attributes are broadly identified in the culture. The COVID-19 related stigmatization pattern could be different based on the sociocultural context.
Commonly sociocultural context represents those forces and reality which influence and often control human thoughts and practices. Study participants' perception, knowledge, belief, religious practices, educational level, political and economic position, and respective attitudes and behaviors were mostly demonstrated in this study in sociocultural context.
The COVID-19-related fear and stigma threaten the lives of healthcare providers, patients (suspected and infected), their family members, and survivors. 11,12 Past outbreaks of infectious diseases are associated with discrimination and stigma across different populations. 12 Notably, social media panic has spread faster than the virus and directly contributes to fear and stigma. [13][14][15] In a recent study on the COVID-19-related infodemic on online platforms, the researchers identified 2311 reports of rumors and stigma from 87 countries. 16 During a pandemic, stigma exerts several adverse effects (e.g., exacerbate physical, social, and psychological distress) on infected individuals. The stigmatization of healthcare providers may adversely affect healthcare provision and efforts to control the spread of the virus. 11,17 Experience gained during past epidemics (e.g., human immunode-

Study design and settings
This study adopted the qualitative study design to explore the process and consequences of stigmatization among a heterogeneous group.
Because the qualitative research reveals the complex phenomenon in the healthcare settings faced by the recipients, healthcare providers, policymakers, and even the clinicians. 23 Data were collected from three divisional cities (largest administrative zone), namely Dhaka, Sylhet, and Chattogram in Bangladesh. Notably, a higher COVID-19 infection and death rate was reported in these three cities. The study was conducted from April to October 2020.

Study population and sampling strategy
We recruited our study participants from the three divisions of Bangladesh to capture their heterogeneity in socioeconomic sta-

Data collection tools and procedures
We conducted 20 in-depth interviews (IDIs) with the suspected or confirmed COVID-19 patients and their family caregivers who experienced stigma by their family members, neighbors, and other associates. Moreover, we conducted five key informant interviews (KIIs) with physicians, local media representatives, leaders, law enforcement officials, and local administrative officials. Instead of focusing on one or two professional groups, we sought to achieve professional heterogeneity when selecting these key informants.
A research team experienced in qualitative methods and techniques collected the data. We developed semistructured interview guidelines for the IDIs and KIIs. The guidelines entailed questions about the events, processes, and experiences associated with stigmatization.
All the study participants voluntarily participated in this study. Both telephone-based and face-to-face interviews were conducted following participants' choice to ensure interviewee and interviewer health safety and compliance with travel restrictions. In addition, we conducted 12 telephone interviews as the participants avoided face-toface talking. The interviews were conducted in Bangla (the mother tongue of the interviewers and interviewees). On average, each interview lasted for 45-60 min. Several follow-up telephone calls were made to collect missing data and further explore specific issues with some respondents. We adopted the data saturation principle (i.e., the point beyond which no new information, theme, or dimension emerged) to determine the required sample size. 24,25

Data analysis
We conducted a thematic analysis to analyze the data. 26,27 We followed the inductive approach for thematic analysis. First, the audiorecorded interviews were transcribed verbatim and translated into English. Then, three researchers repeatedly read the transcripts independently to familiarize themselves with primary data and its meaning. Therefore, a primary open and axial code list was generated. Subsequently, we created clusters based on these codes. Finally, three researchers created themes and subthemes based on the emergent clusters. We randomly reviewed a few interview transcripts to identify and rectify errors in the axial codes. We used memo writing tools to map our data analysis and extract the meaning from primary data. 28 Therefore, the meaning of data helped identify the contributors and process of stigmatization for framing our conceptual framework. Disagreements were resolved through discussions among the team members. The entire data analysis procedure was undertaken manually.

Ethical considerations
This study followed the ethical agreement of the Helsinki declaration.
This research obtained ethics approval by the Research Ethics committee of the Anthropology department of Shahjalal University of Science and Technology. We obtained verbal consent over the phone for mobile interviews about voluntary participation before starting the interview.
We used the pseudonyms of the participants to ensure the privacy and confidentiality of participants. Figure 1 presents the conceptual framework that was developed based on the present findings. Through various interview sessions with the study participants, bullet points were evolved during the conversation. A list of contributors, patterns, and processes of stigmatization and respective reactions was compiled from various interview sessions. Memo-writing methods were adopted here in this listing, and an inductive approach was followed in the compilation. Consequently, they disseminated misinformation to others. This con-

Stigma related to symptoms
Commonly reported COVID-19 symptoms included severe diarrhea, high fever, sleeplessness, throat dryness, sneezing, pain, trigger fingers, a loss of taste and smell, and breathing difficulties. These symptoms created distress in the individuals with suspected or confirmed COVID- 19 and their family members. In addition, these symptoms brought profanity to the suspected or infected individuals and the family members.
All the participants reported that suspected and infected individuals hid their symptoms from their household and family members, individuals in their workplace, and even doctors during their visits to hospitals and clinics. These behaviors were motivated by fear of being ostracized by family members, neighbors, and healthcare providers.

Fear of being infected by other patients
Fear of being infected by other infected patients emerged as a factor that prevented individuals from visiting a diagnostic center. Further, the participants reported that individuals waiting in queues did not practice social distancing or wear masks. Moreover, the informants noted that many visitors were coughing but not wearing masks. Therefore, many individuals reportedly avoided visiting hospitals and diagnostic centers to avoid contact with infected and suspected individuals.
For example, one IDI participant made the following statement: Visitors wear a mask when they talk to others and move from one place to another. But they put their mask in their pocket when they sit on a chair. (

Stigma related to isolation and quarantine
Isolation and quarantine were unfamiliar terms to two-third of the IDI participants. A large majority of the participants did not know about the terms "isolation and quarantine" in their lifetime. These terms were widely used in all COVID-19 related announcements and news. No similar terms in the native language were used. The meaning of these terms was expressed differently by the participants. Such terms resulted in more fear and negligence. During the first few days, I experienced mild fever, a runny nose, and breathing difficulties. After three days, the situation turned into a nightmare as we could not get tested failed to manage the test. We visited most private, and public hospitals/clinics for a diagnosis but could not get tested. (Male, 38 years, suspected patient,

Dhaka)
The participants reported that HIV-positive patients with COVID-19 symptoms shouldered a double burden of victimization. Health service providers did not cooperate to access health facilities. One IDI participant provided the following description: You have a virus (HIV). How could you expect to get tested for COVID-19 here? You will not be tested here." They did not even listen to my words. (Male, 35 years, suspected patient, Chattogram)

Restrictions
Hospitals designated for the treatment of COVID-19 patients had imposed strict restrictions on patient movement and visitor access.
Therefore, suspected patients with mild symptoms were reluctant to seek healthcare services. The participants compared such hospitals to prisons. Nevertheless, most participants continued to engage in their usual activities until their physical health condition deteriorated.

DISCUSSION
This study focused on two major aspects of stigmatization: (a) pro- Stigmatization is a distressing experience that can lead to changes in traditional cultural practices. Therefore, it is important to under-stand the cultural factors involved in the stigmatization process. Without addressing the pertinent sociocultural factors, the prevention, control, and management of public health emergencies (e.g., epidemic and pandemic) will prove to be very difficult.

Limitations of the study
This study has a few limitations. It was not possible to conduct inperson interviews in all cases because of the pandemic. In addition, potential participants declined the invitation to participate in this study because of time limitations, a heavy workload, and unwillingness to be interviewed. Seven potential participants refused to participate in the interview due to COVID-19-related fears. Hospital staff members closely observed stigmatic behaviors. Therefore, they should be included in future studies to examine the responses of stigmatized individuals in greater depth.

CONCLUSION
Aiming to explore the transmission dynamics of the COVID-19 through the stigmatization process among heterogeneous groups of people, this study concluded that diverse sociocultural factors influence the stigmatization. Study findings also revealed that stigmatization accelerates transmission. Healthcare decision-makers and policymakers are trying to devise better strategies to manage this COVID-19 pandemic that has already been identified as a global public health crisis.
But without considering the sociocultural tradition, reality, and practices of the mass people, it is a complex issue to control and manage such a health burden. People understand and respond according to their interpretations, which develop from their contextual reality. It is evolved from this study that various sociocultural factors are the basis of contextual reality that influence stigmatization, ultimately contributing to increasing the transmission flow. A transdisciplinary approach is needed to handle this complex situation effectively. Transmission prevention and control are significant issues in such emerging or reemerging diseases where effective treatment is uncertain.
People's perception, interpretation, and behaviors are vital here. Thus, issues related to the stigmatization process are very significant in preventing and controlling such health crises. The present findings may offer helpful insights to the relevant personnel and policymakers and help them in reexamining issues related to COVID-19-related stigmatization and reduce transmission flow. Further studies on an in-depth exploration of such stigmatization processes and related issues will enrich our understanding of how such unexpected outbreaks can be effectively managed and controlled.

ACKNOWLEDGMENT
We would like to thank the participants for their voluntary participation and cordial cooperation in the study.

FUNDING
Authors received no funding for this research.

CONFLICTS OF INTEREST
The author declare that there is no conflict of interest.

DATA AVAILABILITY STATEMENT
Interview guidelines are available in the supplementary files. Primary data cannot be opened publicly because of ethical limitations.
Interested individuals may contact Mr. Jitu Mia (jitusust@gmail.com), Administrative Officer, Department of Anthropology, Shahjalal University of Science and Technology, for queries.